FORTY-FIFTH WORLD HEALTH ASSEMBLY
Provisional agenda item 34
HEALTH CONDITIONS OF THE ARAB POPULATION IN THE OCCUPIED ARAB TERRITORIES, INCLUDING PALESTINE
The Director-General has the honour to bring to the attention of the Health Assembly the annual report of the Director of Health of the United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) for the year 1991, which is annexed hereto. ANNEX
CONTENTS
Page
EXECUTIVE SUMMARY 3
1. INTRODUCTION 5
2. GENERAL MANAGEMENT 6
3. EMERGENCY OPERATION IN THE OCCUPIED TERRITORIES AND LEBANON 8
4. MEDICAL CARE SERVICES 10
5. HEALTH PROTECTION AND PROMOTION 19
6. NURSING SERVICES 24
7. ENVIRONMENTAL HEALTH SERVICES 31
8. NUTRITION AND SUPPLEMENTARY FEEDING SERVICES 33
9. CONCLUSIONS AND FUTURE DIRECTIONS 35 Annex EXECUTIVE SUMMARY
1. After an Introduction which provides some background concerning UNRWA and its health policies, the chapter on General Management describes how the Health Department is staffed and organized, the role of the World Health Organization, and the Department's budget and finance 1990, 1991 and the 1992/93 biennium. A brief account of staff training follows and the chapter closes with a table showing the categories,
2. The chapter on Emergency Operation in the Occupied Territories and Lebanon provides an overview of the situation in the Occupied Territories of Gaza and the West Bank during the fourth year of the Intifada which was characterized by the sustained level of violence and unrest, rapid worsening of economic conditions in the aftermath of the war in the area of the Persian Gulf, and increased settlement activities. An update on the number of casualties inflicted on the population as a result of confrontations with Israeli security forces and killing of alleged collaborators is also provided.
3. The trend shows a relative decline in numbers compared to early days of the Intifada, which is partly due to the prolonged comprehensive curfews and restrictions on movements. This chapter also provides a brief description of the situation in Lebanon which in spite of marked improvement remains anything but normal and a brief account of UNRWA's emergency and extraordinary measures in these three Fields.
4. Chapter 4 on Medical Care Services deals with what used to be called (rather hopefully) "curative" medical services, that is all the services, medical, dental，in-patient and out-patient provided in UNRWA，s health centres, health points and contracted or associated hospitals, with the notable exception of ”preventive" services such as communicable disease control, maternal and child health care, immunization etc. described in Chapter 5. In the account of Medical Care Services it can be seen that medical consultations agency-wide in 1991 numbered for the first time over 4 million, an increase of 7 per cent, double that which could be expected from natural growth. The increase in the Gaza Field actually exceeded 23 per cent. This is cause for concern, for already the previous year the average number of daily consultations per medical officer in our health centres was over 100，a figure not compatible with adequate quality of care. This problem and how to solve it is the focus of much current effort, some of which is described, including the start of all day (7.00 hours till 19.00 hours) full service which we hope will begin to be provided at the ten most crowded health centres in the five fields in 1992-93. Much progress including 6 new health centres, and 6 new health points (part-time centres) were provided as well as capital projects, infrastructure and hospital renewal.
5. 1991 was the first year of the UNRWA's greatly expanded programme of care for diabetics, and the number of diabetic patients under our care rose by 4200 to 18 900, indicating a significant impact on the unmet need for this level of care.
6. Within Medical Care Services there was a 45% increase in dental consultations, no doubt due to provision of 13 new dental clinics and units. Seven new health centre laboratories were provided, necessary not only to cope with increased general work but especially that connected with new strategies in diabetes and anaemia.
7. The Commission of the European Communities announced in November 1991 its commitment to fund the construction of the new Gaza Hospital for which UNRWA still seeks the costs of equipment, running costs for three years and support to the establishment of a nursing school. This hospital is very desperately needed. Despite having the largest most dependent population of refugees in the Gaza Field, UNRWA spends relatively little on hospitalization there because of the simple lack of accessible facilities to supplement the low bed/population ratio of government hospital facilities. In the other four Fields on the other hand, particularly Lebanon and West Bank, the Health Department is engaged in a constant and wearing struggle to control its hospitalization costs and ensure primacy for primary health care.
8. In the chapter on Health Protection and Promotion some very encouraging trends indeed can be noted. The steady decline in immunizable diseases continued along with the maintenance of very high immunization Annex levels (near 100 per cent of the infants registered at UNRWA Health Centres) and new vaccination strategies. Hepatitis В will hopefully be added to the EPI vaccines at the same time as the host governments and the Israeli Government add it for their own populations.
9. A strong effort was made to redefine goals and strategies in maternal health and family planning care, with some assistance of UNFPA, and some results of this effort will undoubtedly be seen in 1992.
10. Most encouraging were the results of meticulous surveillance of nutritional status of children under three. We may confidently say that as far as 1991 was concerned, despite the deprivation of the Gulf War, no field has any longer a problem of protein-energy malnutrition, except for our refugee infants in Syria. In that field it exists to a mild degree (4.2 per cent below minus 2 standard deviations below the mean weight for age as compared with an expected 2.6 per cent). In retrospect it was probably a wise decision of the Agency, on the recommendation of the Directors of Health and Relief, to make in January to June a massive distribution of food aid, supplied by donors in response to UNRWA's appeal, which included 30 000 tons of flour, 1575 tons of rice, 1475 tons of powdered milk and about 3000 tons of oils/fats. At that time not only had refugees lost thousands of labouring jobs in the Occupied Territories, millions in remittances of family members in the Persian Gulf area, but thus were also for weeks confined to their homes under curfew unable even to shop. However, the child population fortunately survived with no sign whatever of malnutrition.
11. Among expansions of the Department's work are the early stages, in West Bank and Gaza at least of what will grow to be an Agency-wide programme of Mental Health, whose absence for so long from the UNRWA programme is rather inconsistent with the WHO definition of health.
12. Many of the considerable expansions in services described in these two chapters on Medical Care Services and Health Protection and Promotion although they are inadequate to meet the rising demands and expectations, could not even have been possible without the diversion of resources from the midday meal programme to increases in primary health care coverage and quality.
13. Chapter 6 on the Nursing Services describes considerable changes in orientation to a wider context of community health and a most industrious and fruitful effort in a variety of aspects of the whole Health Department programme (Training, Distance Education, Programme Evaluation, Risk Approach) going well beyond the confines of the earlier traditional approach to Nursing.
14. In Environmental Health Services, while there have been the sort of minor improvements characteristic of all years, this remains one of the weakest points in the whole programme of UNRWA. If it were not for the fact that the host governments in the Syrian Arab Republic and Jordan largely solve the problems by their participation in water and sanitation for refugee camps, we would be in an intolerable situation. As it is now, UNRWA is focusing its efforts on Gaza, West Bank and Lebanon. Intensive assessment is taking place and planning has begun (in Lebanon for example). The donor community will soon have the opportunity to demonstrate its commitment to human wellbeing and development in these three Fields by relieving their distressing situations in respect of water and sanitation, the worst being that of Gaza.
15. In the final chapter Conclusions and Future Directions, the Director of Health attempts to analyse some aspects of the experience of 1991, and beyond this to point out some of the more fundamental constraints affecting the achievement of WHO and the Department's ideals and arising from the nature of UNRWA's history and mandate, and indeed the nature of the Palestine refugee problem. Nevertheless, he also tries to point out the main lines along which the Health Department should strive to progress between now and the end of the decade. Annex
1. INTRODUCTION
1.1 Population
Overall the United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) cares for just over two and a half million registered refugees as at 30 June 1991, of whom more than one-third live in camps while the rest live in cities, towns or villages. The registered refugee population is distributed as follows: Lebanon 310 000, Syrian Arab Republic 290 000, Jordan 960 000, the West Bank 430 000 and the Gaza Strip 529 000. In the five geographical areas or territories called Fields of Operation about 2 275 000 refugees are eligible for health care services.
1.2 Health Status
The fact that there has been no population census in any of UNRWA's five Fields since 1967 remains a major obstacle for assessment of health status of refugee population or measurement of progress towards health. There are no reliable sources of information for obtaining demographic data or calculation of rates and indices based on valid denominators.
In the absence of this data-base, assessment of the health status of Palestine refugees is often based on assumptions and on monitoring of changes in the patterns of morbidity and mortality. Such estimates are supported by data collected through the health information surveillance system which has been maintained by the Agency over the past years. However, rates and indices can by no means be considered fully reliable and accurate.
The overall crude birth rate of the refugee population is estimated at 35 per thousand but could be as high as 50 per thousand in Gaza. The infant mortality rate ranges between 30 to 40 per thousand live births and the annual rate of population increase is estimated at about 3 per cent in general, 4 per cent in Gaza. The average family size Agency-wide is estimated at 6 persons.
Coupled with a significant drop in infant mortality rates over the past three decades, the pattern showed continuous decreasing mortality from infectious diseases and malnutrition and a relative increase in death from congenital and other causes which originate in pregnancy and child birth.
1.3 UNRWA Health Care Programme
The UNRWA Health Care Programme, which is basically community health oriented, provides primary health care to the eligible refugee population including: medical care services (both preventive and curative), environmental health services in camps and nutrition and supplementary feeding to vulnerable population groups. The level of service responds to the needs of the refugees which in turn reflects their residence. Camp residents use UNRWA facilities because of ease of access. Many refugees residing outside camps nevertheless use UNRWA health centres, especially for preventive services. Other refugees living in towns or remote villages at a distance from the nearest Agency health centre, tend to share in local community facilities whether private, voluntary or public health.
1.4 Overall Health Policy
UNRWA's policy is to provide essential health services to eligible Palestine refugees consistent with the humanitarian policies of the United Nations and the basic principles and concepts of the World Health Organization and also with the development and progress achieved in public health and medical care provided by the host governments to their indigenous population at public expense. The prime objective of the Agency's health programme is to protect and promote the health of the refugee population by meeting its basic health needs. Annex
2. GENERAL MANAGEMENT
2.1 Organization
2.1.1 The Director of Health is responsible to the Commissioner-General of UNRWA for the planning, implementation, supervision and evaluation of the health programme within the approved Agency policies and established rules, regulations and procedures.
2.1.2 The Department of Health comprises the Director of Health, his Deputy, such secretarial and administrative staff as may be provided, a Training Officer, a Senior Medical Officer (Epidemiology) and the following Divisions, which are directly responsible to him:
-Medical Care Services -Health Protection and Promotion -Environmental Health Services -Nursing Services
2.1.3 In each of the five Fields of the areas of operation i.e. Jordan, the West Bank, the Gaza Strip, Lebanon and the Syrian Arab Republic, the Department of Health is headed by the Field Health Officer who reports directly to the Field Director for administrative purposes and to the Director of Health on technical matters. The Field Health Officer is assisted by his Deputy, and the Field Preventive Medicine Officer, Field Nursing Officer, Field Sanitary Engineer, Field Nutritionist, Field Diabetologist, Field Pharmacist and Field Laboratory Superintendent and other health staff.
2.1.4 Since 1950, under the terms of an agreement with UNRWA, the World Health Organization has provided technical supervision of the Agency's health care programme by assigning to UNRWA Headquarters, on non-reimbursable loan, currently seven WHO staff members including the Agency's Director of Health. The latter is responsible on behalf of the WHO Regional Director for the Eastern Mediterranean, Alexandria, for advising the UNRWA Commissioner-General on all health matters and for the implementation of WHO's policies as they apply to the Agency. Since 1978, when it proved impossible for UNRWA HQ to remain in Beirut, the Department's Headquarters was split between Vienna and Amman. To attempt to achieve the necessary integrated team approach regular visits and meetings are made to Vienna and Amman, but this proves an inadequate substitute for having the whole team in one place.
2.1.5 Despite this difficulty and those which arise from insecurity and constraints on movement between all our Fields, the Department of Health continues to attach great importance to team work, coordinated staff planning and consultation in the development of health projects and the evaluation of health programmes. To this end, meetings of the senior health staff are held at Headquarters and in the Fields, the more important of which are the weekly staff meetings, and the annual or bi-annual conferences of the senior Field and HQ health staff.
2.2 Direction - Supervision
The Director and Chiefs of each Division and Branch undertake periodic visits to each Field to review the work of the Department and ensure that it complies with Agency policies and Technical Instructions, and to give guidance and encouragement to the staff. These Technical Instructions are issued by the Director of Health. Selected WHO technical publications are also adapted and distributed for detailed technical guidance.
The supervision at Field level is undertaken by the Field Health Officer and his senior colleagues.
2.3 Planning and Programming
2.3.1 The Agency's sixth annual review of the Medium Term Plan has set out the Agency's programme plans and operational work plans for the biennium 1992/1993. The plan formed the basis for the policies that have been applied in the preparation of the 1992/1993 biennial budget. Annex
Previously the medium term planning process operated on an independent cycle from the Agency's budgetary process. The Commissioner-General has recently decided that operational planning, based on longer range strategic planning, will now be combined with the Agency's budgetary process. By combining both processes, a closer link will be forged between planning and the budgetary implementation of those plans as well as reducing the amount of time and effort which results from having two separate processes. Long term planning will be expanded to include a four year time framework covering two bienniums. The long term plan will include a broad analysis of needs, priorities and Agency-wide goals and objectives for consideration by the General Cabinet and the Commissioner-General. The plan will also serve as a basis for biennial policy guidance.
2.3.2 The content of the programme in its various specialties, however, the evaluation of progress and needs, the definition or re-definition of objectives and targets and the selection of approaches and strategies to achieve them are frequently decided on or carried out with the assistance of WHO staff from Geneva or Alexandria, WHO consultants, or WHO collaborating centres, and are based on visits, surveys or consultations undertaken at field level.
2.4 Budget and Finance
2.4.1 The following table shows 1990 expenditure on the Health Programme, the 1991 and 1992/93 approved health budgets, by Field:
Gaza Lebanon Syrian Jordan West HQ Total Arab Bank Republic (Thousands of US dollars) 1990 Expenditure 11 412 7 735 7 823 8 493 10 892 1 519 47 874 1991 Approved 11 742 7 153 6 006 8 579 10 780 2 364 46 624 Budget 1992/93 24 809 14 925 12 895 18 697 23 668 7 804 102 798 Approved Budget
2.4.2 Breakdown of the total 1991 approved health budget by cash, in kind, sub-programmes, Capital and Special Projects is shown in the following table:
HEALTH BUDGET, 1991 (IN THOUSANDS OF US DOLLARS)
Cash In Kind Total A. General Fund
Nutrition & Supplementary Feeding 1 942 0 1 942 Medical Care Services 25 589 584 26 173 Environmental Health 7 463 275 7 738 Sub-Total 34 994 859 35 853 B. Funded Ongoing Activities 542 8 264 8 806 C. Capital & Special Projects 1 964 0 1 964 Grand Total 37 500 9 123 46 623 Annex ‘
The great majority of the medical care services expenditure goes to primary health care and preventive medicine.
The 1991 health budget represented approximately eighteen per cent of the overall UNRWA approved budget.
2.5 Development of Human Resources for Health
The Agency maintained and further developed its programme of development of human resources for health. Basic professional and vocational training is primarily the responsibility of the Department of Education, while the in-service and fellowship programme is the direct concern of the Department of Health.
2.5.1 In-service Training
Continuing education was carried out by the Department of Health for its own staff in the various aspects of the programme in accordance with identified training needs and priorities in each Field of UNRWA's areas of operation.
The emphasis of the training activities conducted at Field level was focused on explaining the new approaches and strategies that have been introduced in the programme. In addition, training on emergency medical care and mental health received special attention in the occupied territories.
These training initiatives were complemented by three inter^Held refresher training courses which were conducted at the Centre for Educational Development for Health Personnel, Jordan University during the period 8 June to 4 July 1991. The courses were attended by 75 Medical Officers from the five Fields of UNRWA's areas of operation. Subjects discussed covered mental health, diabetes mellitus, rheumatic fever and rheumatic heart disease, hypertension, rational use of laboratory investigations and rational use of essential drugs.
Furthermore, the Department of Health invited a task force of resource personnel from the Liverpool School of Tropical Medicine, Institute of Child Health/University of London, Institute of Development Studies/University of Sussex, Educational Technology and Community Development/Open University, Save the Children Fund, United Kingdom and Jordan University of Science and Technology in order to develop a comprehensive Distance Education Programme responding to the Agency's needs and priorities, and using modern education/communication techniques to improve the quality of health care delivered through UNRWA health centres in the five Fields. The Task Force met in Amman from 9-18 December 1991 and developed, in coordination with UNRWA senior staff from Headquarters Branch, Amman, and the five Field Health Officers, a project proposal costing about US$ 553 000 over a period of four years starting 1993. Implementation of this project will depend on the feasibility of securing the necessary funding and support.
2.5.2 Post-Graduate Training
Through the sustained support of WHO/EMRO, the UNRWA Health Department continued to maintain an active training programme aiming at developing the technical and managerial skills of its staff and meeting future replacement needs. Seven fellowships for post-graduate studies were awarded, started or completed during the year. Additional post-graduate training opportunities were also provided to eight staff members from other sources.
3. EMERGENCY OPERATION IN THE OCCUPIED TERRITORIES AND LEBANON
3.1 Overview of the situation
As the state of violence, unrest and economic recession remained unabated in the Occupied Territories of Gaza and the West Bank, there was no sign that the situation would ever go back to what it used to be before the Intifada. Annex
The year started with comprehensive and strictly maintained curfews which were imposed by the Israeli authorities all over Gaza and the West Bank since the war broke out in the Persian Gulf area. The entire population, i.e. approximately 1.5 million, were confined to their houses and could not get to their places of work. When the curfews were lifted for short periods at intervals, only women were allowed to move to stock up on food but supplies were short and many did not have cash to buy because they were not able to go to work and so received no wages.
UNRWA activities were greatly hampered. Essential health personnel were allowed access to their duty stations only with valid curfew passes and a great deal of risk and inconvenience, which prevented many staff from getting to their places of work. However, UNRWA clinics were open 24 hours a day to serve anyone who could get to them.
3.2 Casualties
While there has been a decline in the number of curfews, strike days and fierce confrontations in Gaza during 1991, the situation was relatively more tense in the West Bank.
There has been, however, a significant decrease in the number of fatalities and injuries during 1991 compared with earlier in the Intifada as shown below:
GAZA
Year Injuries Fatalities Total 1988 12 005 98 12 103 1989 21 722 136 21 858 1990 16 025 51 16 076 1991 6 396 25 6 421 Total 56 148 310 56 458
WEST BANK
1988 5 228 238 5 466 1989 4 082 197 4 279 1990 4 945 198 5 143 1991 1 755 100 1 855 Total 16 010 733 16 743
The figures given in Table 1 are those reported to or made known to UNRWA and include not only registered refugees but other Palestinians not registered with UNRWA. The figures are by no means exhaustive because they do not include persons who might have sought medical care at private clinics or refrained from seeking medical attention in fear of arrest.
3.3 UNRWA's response
The extraordinary measures which were introduced in 1988 to cope with the new situation were maintained during 1991 including the services of the afternoon clinics in the West Bank and Gaza and the Annex night clinics in Gaza, additional budgetary provisions for emergency supplies, for the hospitalization of Intifada- related injuries and for other emergencies, the services of six physiotherapy clinics each in Gaza and the West Bank, and emergency food distribution, which during the war period covered both the refugee and the non- refugee population.
3.4 Situation in Lebanon
In spite of the significant improvement in the security situation in Lebanon, the general situation remained far from normal. At least 52 Palestinians were lêilled and 184 were injured during three days of fighting when the Lebanese army started its deployment in South Lebanon within the framework of restoring government control in all parts of the country including the Palestine refugee camps of the Saida and Tyre areas. As the clashes went on, virtually all the civilian population of Ein el-Hilweh and Mieh Mieh camps and neighbouring areas fled to safety in other parts of the country.
As soon as the fighting ended on 4 July 1991, civilians in Saida area began returning to the camps and UNRWA officials were able to assess the damage. Among other facilities affected, the water network of Mieh Mieh camp was damaged and some medical supplies were taken from the health centre. In Ein el-Hilweh camp, some 80 refugee shelters were damaged. The health operation was maintained at a lower level with a skeleton staff during the clashes and was resumed at virtually normal capacity with effect from 7 July 1991.
The steady improvement in the security situation continued to be marked throughout Lebanon with the exception of the South, which remained tense as a result of the Israeli air-strikes and heavy shelling by the South Lebanese Army (SLA). A Palestinian refugee was killed and three others were injured in Rashidieh camp on 29 October 1991 when Israeli helicopters opened fire on the area with machine guns.
4. MEDICAL CARE SERVICES
4.1 General
UNRWA provides medical care services which comprise out-patient and in-patient medical care, dental care, rehabilitation of physically disabled persons, essential diagnostic and support services such as laboratory and radiological services, specialist and special care services and provision of medical supplies.
4.2 Objectives
4.2.1 To reduce morbidity, disability and premature mortality from communicable and noncommunicable diseases by developing and maintaining appropriate surveillance/intervention strategies based on appropriate current medical technology and consistent with the basic principles and concepts of the World Health Organization.
4.2.2 To enhance the ability of individuals, families in general and at risk groups in particular to develop to their full health potential by assuming responsibility for their own health, avoiding self-inflicted damaging behaviour and fostering life-styles conducive to good health.
4.3 Progress during the year
The demand on UNRWA medical care services, be it general clinic services, hospital services or other support services, continued to be high in all Fields due to the rapid inflation, increased cost of medical care, worsening socioeconomic conditions and the emergencies prevailing in the Occupied Territories and Lebanon which have been compounded by the war in the area of the Persian Gulf and the subsequent huge influx of Palestine refugees to Jordan. Annex
TABLE 1. CASUALTIES IN THE OCCUPIED TERRITORIES IN 1991
TOTAL Rubber Tear Camp/area Shot Beaten bullet Other Residents/ gas Registered wounds All status refugees unknown I. Gaza Strip Total injuries 1 251 4 813 9 277 46 6 396 1 599 4 797 Fatalities 23 0 0 1 1 25 6 19 Total casualties 1274 4 813 9 278 47 6 421 1605 4 816 II. West Bank Total injuries 505 673 177 242 158 1 755 1 230 525 Fatalities 84 0 0 0 16 100 92 8 Total casualties 589 673 177 242 174 1 855 1322 533 Children under 15 I. Gaza Strip Injuries Under 1 year 0 1 0 106 0 107 3 104 1-5 years 10 178 1 24 3 216 60 156 6-10 years 46 622 0 15 10 693 249 444 11-15 years 357 1 025 2 19 7 1 410 337 1 073 Total injuries 413 1 826 3 164 20 2 426 649 1 777 Fatalities 7 2 0 0 0 9 0 9 Total casualties 420 1 828 3 164 20 2 435 649 1 786 II. West Bank Injuries Under 1 year 0 1 0 42 0 43 11 32 1-5 years 3 19 5 40 10 77 25 52 6-10 years 24 44 15 23 10 116 61 55 11-15 years 118 141 45 29 38 371 282 89 Total injuries 145 205 65 134 58 607 379 228 Fatalities 13 0 0 0 0 13 12 1 Total casualties 158 205 65 134 58 620 391 229
Notes: 1. The figures are those reported to or made known to UNRWA and should not be treated as exhaustive. 2. The figures against Fatalities do not include killings of alleged "collaborators". Annex
4.3.1 Out-patient medical Care
4.3.1.1 Medical Consultations. In spite of the emergency situations prevailing in three fields, often resulting in disruption of services and poor access to UNRWA facilities, the number of medical consultations Agency- wide was increased by more than 1% compared with that of 1990’ with the highest increase in Gaza Field (23.6%).
4.3.1.2 An evening shift clinic was established at Jerusalem Health Centre, West Bank, to provide medical care to patients with the main objective of controlling self-referrals to Augusta Victoria Hospital (AVH). Also three new health points were established in Qasmieh, Shabriha and Ma'achouck villages in lyre Area, Lebanon. Furthermore, medical care services started to be provided at Seilet Al Harithiyeh health point, West Bank, and a new health point was established at Mashar’e, Jordan Valley.
4.3.1.3 Patient Flow Analysis. In coordination with consultants from WHO, Geneva, and CDC, Atlanta, Patient Flow Analysis (PFA) was carried out in West Bank and Gaza Fields. The other three Fields had conducted PFA at an earlier stage and started to apply the results obtained from this operational research for improving general clinic and Maternal and Child Health services.
The results obtained from this operational research have been used in the five Fields for reorganization of services at UNRWA health centres by introducing appropriate appointment systems on trial basis effective 1991.
The appointment systems will be further developed and expanded after thorough appraisal of the trial, review of staffing standards and education of patients.
4.3.1.4 Medical Manpower. A study was undertaken by the Health Department on the average Medical Officers' workload per day per centre in 1984 and 1990 in each Field. The study revealed that our Medical Officers undertake an unreasonable number of medical consultations which affect the quality of patient care. The daily average per Medical Officer ranges from 73 in Lebanon to 123 in Gaza with an average of 101 Agency-wide. Owing to space being limited, it has been recommended that a two shift 砂stem, with a second team working from 13h00 till 19h00 be implemented in the largest health centres. The Commissioner-General approved that this arrangement be implemented in Jabaiia, Rimal, Nuseirat, Khan Younis and Rafah in Gaza where the Agency has so far been prevented by the Civil Administration (the term given to the Israeli administration in Gaza and West Bank) from building new health centres to reduce the pressure on the main health centres.
4.3.1.5 Capital Improvements. The projects for construction/extension of new health premises and replacement of inferior health facilities progressed as follows:
• In Jordan, works for construction of a new Maternal and Child Health centre in Jabal Nuzha and construction of a health training centre in Amman were completed. Progress was achieved with respect to construction of new health centres in Amman New Camp and Suf camp (to replace old dilapidated premises).
- In West Bank, works for construction of new health centres in Deir Ammar and Fawwar were completed. Extension works at Qalqilia health centre and the hospital ward were also completed. Works for construction of a new Field Pharmacy in Jerusalem and Doura health centre to replace the old unsatisfactory premises are nearing completion.
- In Lebanon, works were started for reconstruction of Buss health centre. Works for renovation of Buij el-Barajneh and Ein el-Hilweh health centres were completed. Also construction of Ein el-Hflweh Maternal and Child Health centre was completed. Saida Town health centre and Saida temporary clinic were accommodated in one rented premises and the Field Pharmacy was relocated from Siblin Training Centre to the Central Warehouse in Beirut.
- In the Syrian Arab Republic, works were started for renovation of Dera'a health centre. Annex
- In Gaza, works were started for construction of a new health centre in Deir el-Balah camp to replace the old unsatisfactory premises and for major renovation of Jabalia health centre. In addition, works for construction of a new Field Pharmacy were progressing. Unfortunately the projects for construction of health centres in Beit Hanoun (Jabalia), Beach Camp and Tel El-Sultan (Rafah) could not as yet be started due to prevention or delay by the Civil Administration.
4.3.1.6 Control of Noncommunicable Diseases. Programmes for control of noncommunicable diseases were provided by 30 specialist clinics which include clinics for cardiovascular diseases, ophthalmology, paediatrics, dermatology, ENT, gynaecology and obstetrics and respiratory diseases. The services provided by these specialist clinics were complemented by 163 special care clinics for diabetes and hypertension (see Table 2). These clinics were expanded during 1991 by establishment of fifteen additional hypertension clinics, fourteen diabetes clinics, three ENT clinics, three ophthalmology clinics and three cardiovakmlar clinics in Lebanon; two diabetes clinics and 21 hypertension clinics in the Syrian Arab Republic; one cardiovascular and nine hypertension clinics in Gaza; 13 diabetes clinics, two hypertension clinics, one dermatology clinic and one gynaecology clinic in West Bank; five hypertension clinics and four diabetes clinics in Jordan. (For details on specialized diabetes care see Table 3).
UNRWA strengthened its diabetes programme by recruiting a Chief Diabetology at UNRWA Headquarters Branch, Amman and five Field Diabetologists, establishment of a diabetes team in each Field, providing the medical supplies recommended by WHO consultants and improving the pertinent health education programme. In addition, the Manual on Diabetes Mellitus for UNRWA health staff and four educational video tapes for health staff and diabetic patients on diabetic diet and application of insulin were finalized and distributed to the five UNRWA fields. The Manual was distributed to WHO regional offices and HQ, Geneva and will also be distributed to the Public Health Department of the Civil Administration and nongovernmental organization health care providers in the Occupied Territories, and to the Ministers of Health and key health officials of Jordan, Syrian Arab Republic and Lebanon. An Arabic version is under preparation.
Effective 1991, diabetic care has been provided from all health centres and health points as an integral part of UNRWA’s primary health care facilities.
4.3.2 In-patient (Hospital) Care
4.3.2.1 Hospitalization Schemes. In all Fields UNRWA maintained its hospitalization schemes at private contracted hospitals by meeting the additional cost of service.
- In Jordan, the contractual agreements with subsidized hospitals were terminated and provisions of the existing reimbursement scheme were improved effective 1 January 1991. Owing to the high demand on UNRWA hospital services and the high number of Palestinian returnees from the Gulf, the approved budget provisions proved to be inadequate to meet the needs.
• In Gaza, five additional orthopaedic beds were subsidized at Al Ahli Arab Hospital.
- In West Bank, the agreement between UNRWA and the Lutheran World Federation (LWF) with respect to Augusta Victoria Hospital (AVH), Jerusalem, was revised whereby the number of subsidized beds was increased from 110 in 1991 to 118 in 1992. (The cost of this increase is to be met in part by UNRWA's ceasing to subsidize the cost of out-patient visits, decreased reliance on Hadassah Hospital, West Jerusalem, and increased use of the less expensive Makassed Hospital, East Jerusalem).
- In Lebanon，the number of contracted beds was reduced by 36% to meet the continuous increase in cost of hospital services. Additional funds over and above approved budget nevertheless had to be allocated to avoid interruption of services. Annex
TABLE 2. OUT-PATIENT SERVICES
(a) Number of Health Units Field Health Dental* Laboratories Specialist Special Care Clinics Units Clinics Clinics Diabetes Hypertension Jordan 20 16 13 8 16 11 West Bank 33 10 10 2 24 2 Gaza 16 8 7 5 9 9 Lebanon 25 8 6 13 25 25 Syrian Arab Republic 22 8 11 2 21 21 Total 116 50 47 30 95 68 (b) Number of Attendances Jordan West Bank Gaza Lebanon Syrian Arab All Fields Republic � Medical Consultations First visit 272 066 148 802 252 839 125 803 143 403 942 913 Repeat visits 767 456 543 217 902 815 447 408 554 662 3 215 558 Sub-total 1 039 522 692 019 1 155 654 573 211 698 065 4 158 471 (U) Other Services Injections 70 217 86 244 457 886 55 828 44 903 715 078 Dressings 146 335 118 346 233 995 80 406 65 112 644 194 Eye Treatments 55 479 16 569 118 107 24 795 7 172 222 122 Sub-total 272 031 221 159 809 988 161 029 117 187 1 581 394 (Ш) Dental Consultations 134 139 50 282 78 831 58 213 50 591 372 056 (c) Average Number of Attendances/1000 Eligible Population Medical Consultations First Visit 309 442 478 469 552 414 Repeat Visits 871 1 612 1 707 1 669 2 133 1413 Injections 80 256 866 208 172 314 Dressings 166 351 442 300 250 283 Eye Treatments 63 49 223 93 28 98 Dental Consultations 152 149 149 217 194 164 * Including mobile dental units. TABLE 3. STATISTICAL DATA ON DIABETES CARE
HELD GAZA LEBANON SYRIAN ARAB JORDAN WEST BANK ALL FIELDS REPUBLIC
No. of Diabetes Clinics 9 25 21 16 24 95 1. No. of Eligible Population 529 000 268 000 260 000 881000 337 000 2 275 000 2. No. Registered: (a) As on 1.1.91 4 024 2 086 1789 4 145 2 686 14 730 (b) No. added during 1991 1 707 568 380 1801 1230 5 686 (c) No. withdrawn as: (i) Dead 68 68 34 76 82 328 (ii) Non attendance (more 134 302 64 310 335 1 145 than 6 months) (d) No. of patients as at 31.12.91 5 529 2 284 2 071 5 560 3 499 18 943 Prevalence rate per 100 000 1045 852 797 631 1038 833 population
ID* NID** ID NID ID NID ID NID ID NID ID NID 3. Type of Diabetes and Age: (a) 0-19 years 31 - 25 - 24 - 87 - 36 203 (b) 20-39 years 249 184 55 95 54 53 225 194 172 76 755 602 (c) 40-59 years 214 2 425 82 964 108 985 426 2 657 191 1466 1021 8 497 (d) 60 years & over 141 2 285 74 989 73 774 211 1760 69 1489 568 7 297
Total 635 4 894 236 2 048 259 1812 949 4 611 468 3 031 2 547 16 3% 4. Risk Factors: (a) Blood relatives of diabetics 2 323 1028 927 2 641 1022 7 941 (b) Obesity (+20% of standard 2 805 775 1014 2 778 1175 8 547 body weight) (c) Vascular disease 636 315 435 387 301 2 074 (d) Obstetric history of large 104 91 30 61 43 329 babies, stillbirths & miscarriages Anne^шюx A45/zFbop/ф 5
16
STATISTICAL DATA ON DIABETES CARE (continued)
HELD GAZA LEBANON SYRIAN ARAB JORDAN WEST BANK ALL FIELD REPUBLIC
5. Complications: (a) Retinopathy 1046 450 135 421 386 2 438 (b) Nephropathy 475 252 64 377 96 1 264 (c) Neuropathy 1854 240 190 819 456 3 559 (d) Cardiovascular 918 627 307 807 629 3 288 (e) Cerebrovascular 174 110 70 174 84 612 (f) Peripheral Vascular 300 265 68 364 121 1 118
Total 4 767 1 944 834 2 962 1772 12 279
6. Type of Treatment: (a) Diet only 613 638 382 663 135 2 431 (b) Insulin therapy 957 228 272 860 704 3 021 (c) Oral therapy 3 921 1388 1374 4 003 2 656 13 342 (d) Oral + Insulin therapy 38 30 43 34 4 149
Total 5 529 2284 2 071 5 560 3 499 18 943 ID = Insulin Dependant Diabetes Mellitus. NID = Non-Insulin Dependant Diabetes Mellitus. Annex
-In the Syrian Arab Republic，approved budget provisions proved to be inadequate, and additional funds were secured in order to overcome the growing difficulties and rapidly increasing hospitalization expenses.
4.3.2.2 Gaza Hospital Project. The Agency concluded a Special Service Agreement with the British consultants, Battersby, Leach and Langslow for preparation of a design brief, operational plan and management advice. The Director of Health and the consultants held meetings in Gaza with an informal ad- hoc consultative committee comprising all institutions providing health care in the Gaza Strip, in order to present and discuss the types of services and specialties needed in the hospital. The Civil Administration indicated that UNRWA could not build the hospital as planned on a site near Gaza City, but provided an alternative site in the south. Also an Equipment Specialist was appointed in order to prepare equipment schedules, specifications and tender review. In November 1991, the consultants revised the Development Plan and prepared a description of the hospital Design Scheme. Also a project Manager (Gaza Hospital) was appointed. At the end of November 1991, the Commission of the European Communities confirmed that it would cover the cost of construction of the hospital allocating 13 million ECU ($ 16.66 million) for this purpose. In December 1991, the contract for the Executive Design Team Services (i.e. the complete architecture) and site supervision was awarded to Architects Co-Partnership (ACP) which was the lowest among eight bidders. Site survey and soil testing would hopefully start in January 1992, and the detailed architecture would be completed in time which would enable UNRWA to invite bids for and award the contract for construction by December.
4.3.2.3 Support to Nongovernmental Organization Hospitals. The Agency was also successful in seeking special donations for upgrading the standard of facilities and equipment at subsidized hospitals in West Bank and Gaza.
4.3.2.4 Individual Patient Subsidies. The Agency maintained a scheme for reimbursement of costs of hospitalization to special hardship cases and other eligible refugees in Gaza, West Bank and Jordan Fields. In Lebanon Field, a new technical instruction on reimbursement of hospital expenses was issued for implementation effective 1 January 1992.
4.3.2.5 Emergency Life Saving Treatment. UNRWA continued to meet part of the cost of specialized emergency life-saving treatment, mainly for cardiac and neuro-surgery.
4.3.3 Ora丨 Health
4.3.3.1 Dental Treatments. The number of dental consultations Agency-wide increased by more than 19%, with the highest increase in Lebanon Field (31%). This substantial increase was mainly due to expansion of oral health facilities and implementation of an active case-finding and management approach.
4.3.3.2 Expansion of Dental Care Facilities. Major developments in the Agency's oral health programme were attained by establishment of additional dental teams and provision of capital equipment.
-In Jordan, three dental units were installed at the Jordan Valley health points. Also two mobile dental clinics were equipped and handed over to the Agency. They will provide services to schools and Maternal and Child Health centres in Amman and Balqa areas.
• In Lebanon, three dental units were received and installed at Beddawi, Shatila and Buij el-Barajneh health centres.
-In West Bank, two dental units were received and installed at Arroub and Jerusalem health centres, and a mobile dental unit was received and put into operation.
• In Gaza, a new mobile dental unit was received and started providing services to Khan Younis and Rafah schools.
In Syrian Arab Republic, a new dental clinic was established in Homs health centre. Annex
4.3.3.3 New Oral Health Strategy. The above major developments provided the necessary infrastructure needed for developing and maintaining a health strategy based on wider coverage and at risk approach, directed towards school children, pregnant women and nursing mothers. This strategy was further reinforced by carrying out oral health surveys, active surveillance and health education activities. In this respect, Dr D. Barmes, Chief, Oral Health ’ WHO, Geneva undertook a mission to Gaza, West Bank, Jordan and Syrian Arab Republic Fields for reassessment of UNRWA,s oral health services from 20 April to 4 May 1991, with special emphasis on development of appropriate intervention strategies to reduce the prevalence of dental diseases.
4.3.3.4 UNRWA staff from Syrian Arab Republic and Lebanon Fields attended the WHO "Inter-Country Meeting on Development of Comprehensive Oral Health Policies" which was held in Damascus during the period 28 Aprü-2 May 1991.
4.3.4 Laboratory Services
4.3.4.1 Expansion of Services
-In Jordan, two additional laboratories were established in Baqa'a and Marka Maternal and Child Health centres.
-In Syrian Arab Republic, three clinical laboratories were established in Lattakia, Sbeineh and Khan Dannoun health centres.
-In Gaza, funds were allotted to establish a clinical laboratory in Bureij health centre.
-In West Bank, three clinical laboratories were established in Askar, Dheisheh and Shu'fat health centres.
-In Lebanon, all contractual arrangements with private laboratories were terminated except the contract for performance of advanced laboratory investigations at the American University Hospital. These measures were taken in order to reduce reliance on private institutions as a result of developing UNRWA,s own laboratory facilities.
4.3.4.2 A draft "Manual on Basic Techniques for UNRWA Laboratory Personnel" has been prepared with a view of standardizing laboratory equipment, supplies, tests and procedures Agency-wide.
4.3.5 Rehabilitation Services
4.3.5.1 Physiotherapy Programme in the Occupied Territories. In addition to the modest provision of contractual services, UNRWA maintained a physiotherapy programme in Gaza and West Bank Fields through a special project established in collaboration with UNICEF.
In Gaza Strip, 1129 patients were treated in Jabalia, Rimal, Nuseirat, Bureij, Khan Younis and Rafah physiotherapy clinics during 1991.
In West Bank, 1035 patients were treated in Balata，Qalqilia, Tulkarm, Jenin and Dheisheh physiotherapy clinics during the year.
UNICEF submitted a draft plan of action for continuation of the joint UNRWA/UNICEF physiotherapy programme in West Bank and Gaza during the biennium 1992-1993. The plan proposes main strategies to achieve a smooth and effective transition whereby locally recruited staff would take over responsibility for overall supervision of the programme by December 1993, by which time the two international physiotherapists will be withdrawn.
4.3.5.2 Treatment of Crippled Children. Crippled children received treatment as out- or in-patients at contractual physical rehabilitation centres both private and governmental. In Jordan Field, crippled children Annex received similar care at the government rehabilitation centre in Amman and the UNRWA physiotherapy centre at Baqa'a camp.
4.3.5.3 Provision of Appliances. UNRWA also continued to provide financial support towards the cost of prosthetic devices recommended on medical grounds such as eye-glasses, hearing-aids, orthopaedic devices and wheel chairs for school children and others who suffer functional impairments and disabilities.
4.3.6 Medical Supplies
4.3.6.1 Drug Formulary. In order to help UNRWA Medical Officers make rational use of the drugs that are available in UNRWA's Medical Supplies Catalogue, a drug formulary was prepared which will be used as a ready reference for prescribing doctors. The formulary has been forwarded to the Regional Adviser on Pharmaceuticals and Diagnostic Substances, WHO Regional Office for the Eastern Mediterranean for review before its issue in a final form to the five Fields.
4.3.6.2 Purchases and Contributions. The value of medical supplies and equipment received as contributions to UNRWA health centres and subsidized hospitals amounted to US$ 241 136, while purchases during the year totalled US$ 3 053 932. This included supplies and equipment for the regular programme，the extraordinary (emergency) programme in the Occupied Territories and Lebanon and the Expanded Programme of Assistance in Gaza and the West Bank.
Vaccines, disposable syringes and cold chain supplies for the Expanded Programme on Immunization continued to be provided through the sustained support of UNICEF. Special vaccines programmed in the Occupied Territories (Inactivated Polio Virus, IPV and Measles, Mumps and Rubella, MMR) were provided by the Civil Administration.
5. HEALTH PROTECTION AND PROMOTION
5.1 General
5.1.1 Health Protection and Promotion Services represent the backbone of UNRWA's Primary Health Care Programme. They comprise epidemiological surveillance and control of communicable diseases; maternal and child health services; school health services; and health education.
5.1.2 More emphasis is being placed on development and implementation of new protective health strategies for management of growth-retarded children; management of iron-deficiency anaemia; risk approach in maternal health; and mental health.
5.2 Objectives
The objectives of UNRWA's health protection and promotion services are:
5.2.1 To reduce morbidity, disability and mortality from communicable and certain noncommunicable diseases by implementing the strategies and approaches adopted by WHO for realization of the global goal of health for all by the year 2000.
5.2.2 To protect/preserve and promote the health of vulnerable and at risk population groups through regular monitoring, group screening, prophylactic immunization, nutritional support and implementation of at-risk strategies/approaches in primary health care.
5.2.3 To reduce self-inflicted health-damaging habits and encourage positive behaviour conducive to good health through health education/health promotion activities. Annex
5.3 Progress During 1991
5.3.1 Communicable Disease Prevention and Control
5.3.1.1 UNRWA maintained an effective surveillance and control system against communicable diseases preventable by immunization (Expanded Programme on Immunization target diseases) and other communicable diseases.
Close liaison was maintained with the ministries of health of host governments, public health departments and WHO, Geneva and Alexandria for exchange of information and coordination of control measures.
UNRWA also participated in the Annual Meeting of the Global Advisory Group of the Expanded Programme on Immunization which was held in Antalya, Turkey, in October 1991 and in the WHO/EMRO Intercountry Workshop on Surveillance of Expanded Programme on Immunization Diseases which was held in Amman in November 1991.
5.3.1.2 Data collected during 1991 confirmed the absence of major epidemics of Expanded Programme on Immunization target diseases and a steady decline in the incidence rates of these diseases. No cases of poliomyelitis, diphtheria or tetanus were reported from any of the five Fields. Should this steady trend of zero incidence be maintained UNRWA would be ahead of the WHO target of eradication of poliomyelitis and elimination of tetanus neonatorum in the Eastern Mediterranean Region by the turn of the century.
The incidence of measles dropped from 20 per 100 000 population in 1990 to 5.3 in 1991. This drop could be attributed to the high immunization coverage, the natural epidemiological fluctuations of disease and the mass vaccination campaign which was conducted in cooperation with the Civil Administration in Gaza among elementary school children in anticipation of a possible outbreak. Also the incidence of rubella dropped from approximately 23 per 100 000 in 1990 to 14 per 100 000 in 1991. It is worth mentioning that MMR vaccine is provided in Gaza and West Bank, whereas measles and rubella vaccines are given separately in Jordan, Lebanon and Syrian Arab Republic.
Meanwhile, the incidence of respiratory tuberculosis remained at the same level of 1990 i.e. 4 per 100 000 population.
5.3.1.3 The standing Technical Instructions on Expanded Programme on Immunization were revised in order to cater for the new changes introduced in the programme and to define immunization procedures in maternal and child health clinics and schools. Implementation of the new technical instructions have greatly improved the quality of immunization services. Meanwhile, the high immunization coverage recorded in previous years was sustained.
5.3.1.4 Poor environmental health conditions, especially in Gaza, leave the refugee population highly exposed to diseases transmitted through environmental channels. Although proper case management with oral rehydration salts had dramatically reduced mortality from diarrhoeal diseases, morbidity from diarrhoeal diseases, dysentery, infectious hepatitis and enteric group fevers showed no significant decrease. A recent survey conducted by the Bir Zeit Community Health Department in Beach camp, Gaza, revealed that intestinal parasites, especially ascariasis, are highly prevalent among school children and detailed a number of associated factors.
Brucellosis remains endemic in the region, mainly in Syrian Arab Republic and the West Bank. The highest incidence rates were reported from the West Bank i.e. 62, followed by Syrian Arab Republic i.e. 32 per 100 000. Leishmaniasis (cutaneous) also remains endemic in northern areas of Syrian Arab Republic, where the incidence rate in 1991 was 20 per 100 000.
5.3.1.5 The high prevalence of Hepatitis В in the region and its long term public health effects received more recognition and attention. The Director of Health represented WHO and UNRWA in a technical seminar on Hepatitis В held at Maqassed Hospital in Jerusalem in November 1991 where the feasibility of implementing a Annex programme of prevention through inclusion of Hepatitis В Vaccine in the Expanded Programme on Immunization was considered.
The Director of Health raised this matter with the ministers of health of host governments and Chief Medical Officers of the Civil Administration, Gaza and West Bank, with a view to coordinating future policies and securing vaccine supplies through contributions in kind or at an affordable cost.
However, until a final decision with respect to integration of Hepatitis В vaccine in the Expanded Programme on Immunization is taken, the Department of Health started to vaccinate all staff at risk, including doctors, nurses, midwives, dentists and laboratory technicians against the disease. The initial requirements of vaccine supplies were provided as contribution in kind from WHO, Geneva.
Meantime, UNRWA launched an immunization campaign against Hepatitis В at its health centre in Baqa'a camp as part of the joint campaign sponsored by WHO, the University of Jordan and the Ministry of Health, Jordan.
5.3.1.6 The refugee population appears to be at a very low risk of contracting AIDS. Nevertheless it is readily recognized that social and behavioural changes may affect morbidity patterns.
In realization of the UNRWA/WHO Short-Term Plan of Action on HIV/AIDS Prevention and Control, a training workshop for senior health staff and technologists in blood transfusion services in the West Bank and Gaza was held at Mount David Hospital, Bethlehem, during the period 1-19 July 1991. WHO, Geneva provided the services of four consultants/facilitators for this purpose, namely, Dr J. Lockyer, Dr A. Archer, Dr J. Ord and Dr J. Emmanuel.
Meantime, WHO provided ШУ examination kits for nongovernmental organization hospitals in West Bank and the Central Blood Bank in Gaza to enable them to test the blood for HTV.
It is worth mentioning that three cases of positive HIV/AIDS were reported during the year: two cases from Lebanon and one case from West Bank. All cases were attributed to blood transfusion during hospitalization several years ago.
5.3.2 Materna丨 Health Care
5.3.2.1 UNRWA provided medical supervision/protection to pregnant women and nursing mothers through regular monitoring of those registered at its maternal and child health clinics as early as possible after establishment of the pregnancy status，throughout pregnancy, at the time of delivery and during the nursing period. The strategy related to deliveries is to provide assistance to women in labour either at camp maternity centres, where such facilities are available, or to ensure safe delivery at home by trained midwives or supervised traditional birth attendants, and to refer high risk pregnancies to subsidized hospitals or otherwise provide financial assistance towards such care at local hospitals.
5.3.2.2 A workshop on maternal health and family planning was held in Larnaca, Cyprus, with participation of all Senior Health Staff in Headquarters and the Fields and two Consultants from the jordan Family Planning and Protection Association, Jerusalem, and the Ministry of Health, Syrian Arab Republic.
Important recommendations were made during this workshop for formulation of appropriate strategies to improve the quality of antenatal, natal and post-partum care with special emphasis on higji risk pregnancies, application of a uniform risk scoring system, investigation and prevention of maternal deaths and provision of family planning services in all Fields as an integral part of the Agency's maternal and child health services.
Relevant technical instructions will be developed and plans for staff training will be implemented in order to introduce services for fertility regulation on demand, particularly with the aim of avoiding pregnancy with short birth intervals, or in grand multiparas or after the age of 35-40. Annex
Furthermore, a system of confidential enquiries of maternal deaths has been developed with the aim of defining avoidable factors and decreasing maternal mortality. The system establishes mechanisms for this purpose between UNRWA staff, obstetricians, government and nongovernmental organization hospitals and the family.
5.3.2.3 In response to UNRWA's project proposals, the United Nations Fund for Population Activities (UNFPA) funded the maternal health/family planning workshop held in Larnaca in November 1991 and expressed willingness to fund an expanded maternal health programme in the occupied territories at approximately US$ 600 000 for three years starting 1992. The joint UNRWA/UNFPA project comprises assistance in research, training and supplies for an improved maternal and family planning service.
5.3.2.4 The number of pregnant women under supervision increased from 55 000 in 1990 to 60 445 in 1991, representing an overall increase of 9 percent, with the highest rate reported from Jordan, i.e. 20 percent, followed by Gaza, i.e. about 9 percent, whereas there was a drop of about 5 percent in the numbers reported from Lebanon. For more relevant statistical data please refer to Table 8.
5.3.2.5 Out of all deliveries reported in 1991 Agency-wide, 64 percent took place at subsidized and government hospitals, 20 percent at home, attended by Agency-trained midwives or by traditional birth attendants, and 16 percent took place at UNRWA maternity centres. In Gaza, where UNRWA operates six maternity wards (65 beds), 34 percent of the total number of deliveries took place at these maternities with only 11 percent at home, and 55 percent in hospitals.
5.3.3 Child Health Care
5.3.3.1 UNRWA provides medical care supervision/protection to infants and pre-school children, through regular growth monitoring and immunization of those registered at its maternal and child health clinics, as early as possible after birth, up to three years of age and to children 3-5 years of age who require special attention. The service also comprises immunization against the six Expanded Programme on Immunization target diseases, namely, tuberculosis, diphtheria, pertussis, tetanus, poliomyelitis and measles. The strategy for prevention of congenital rubella syndrome has been changed in line with that of many industrialized countries, and rubella vaccine is now included in the infant immunization programme. Children showing growth retardation receive special health care in accordance with new Health Technical Instructions.
5.3.3.2 Analysis of data reported from the five Fields of UNRWA's areas of operation revealed that the number of children 0-3 years who were under supervision in our clinics increased from 165 000 in 1990 to approximately 177 000 in 1991. The highest rates of increase were reported from Gaza and Jordan i.e. about 15 percent each, whereas there has been a drop of about 5 percent in the number of children under supervision in Syrian Arab Republic Field. For statistical data please refer to Table 8.
5.3.3.3 During 1991, the Department of Health further strengthened its nutritional surveillance system of children below three years of age by monitoring of trends based on data reported from its maternal and child health clinics on a monthly basis. Also, beginning in 1991, the old sex^ombined growth charts were replaced by separate-sex WHO international weight-for-age standard charts.
The overall prevalence rate of growth retardation among children below three years of age remained largely consistent with the findings of the WHO/UNRWA nutritional survey which was conducted in all Fields during 1990.
The overall prevalence rate of growth retardation among children was 2.5 percent for infants below one year, 3.3 percent for children aged 12-23 months and 1.8 percent for children aged 24-35 months. However, Table 9 and the relevant illustrations clearly show that a large proportion of these children fall under the first degree underweight. It is expected that 2.6% of children in normal distribution fall below minus 2 standard deviations (SD) below the mean, and it can justly be said that except in Syrian Arab Republic, refugee children no longer have a problem of protein-energy malnutrition. If, therefore, we exclude this group of children, the net prevalence rates of growth retarded children would be 6 per thousand for children 0.23 months of age and 3 per thousand for children 24-35 months of age, which are negligible, especially if we take into consideration Annex that detailed epidemiological investigation revealed that the majority of these children suffer from medical problems and congenital diseases rather than from nutritional problems per se.
This could be further ascertained by the fact that the seasonal variations identified in three Fields (see relevant illustrations) were mainly manifest among children who fall under the first degree underweight whereas, the rates remained more or less stable among those in the second and third degree underweight of the international scale.
5.3.3.4 Intensified efforts to reduce the prevalence and severity of iron deficiency anaemia inevitably led UNRWA to pay greater attention to congenital haemolytic anaemias. They emerged in 1991 as a significant public health problem among refugees in Syrian Arab Republic, Gaza and Lebanon. A number of cases who require special drug therapy and regular blood transfusion were reported by health staff in these Fields.
Early detection and treatment of thalassaemia is essential to prolong the life span of the affected children, but it is also indispensable to put in place a preventive programme. As a result, plans are being developed to enable UNRWA central laboratories in each Field to identify carriers of the beta-thalassaemia and sickle cell traits. After this is achieved, close relatives of index cases can be examined and assisted with genetic counselling. Health staff members will receive training in order to fulfil these tasks efficiently.
5.3.4 Mental Health
5.3.4.1 Because of limited resources and other competing priorities, mental and psychological health problems did not receive adequate attention in the past. This matter received more recognition and planning during 1991 in the light of the noticeable increase in mental health disorders among the refugee population as a result of the emergencies prevailing in three Fields and the worsening economic conditions especially in the aftermath of the war.
5.3.4.2 A joint WHO/UNRWA Mental Health Programme started in May 1991 in West Bank. The objectives of the one-year joint project, which will afterwards be taken over by UNRWA, include reduction of the prevalence of mental health problems among children by dissemination of information and provision of counselling services and treatment. It also includes training of UNRWA medical staff, social workers and teachers in order to improve their knowledge of psychopathology and skill in dealing with associated problems.
5.3.4.3 The agreement between UNRWA and Gaza Community Mental Health Programme (GCMHP) was renewed for a second year until the end of December 1991. The agreement covers treatment of cases referred by UNRWA Medical Officers to GCMHP and training of medical staff, teachers and social workers in management of mental health problems especially post-traumatic stress disorders syndrome among children.
5.3.4.4 A WHO Consultant, Dr Nago Humbert, carried out in coordination with UNRWA medical staff, Lebanon, an "Evaluation of Health Structure and of the Psychological Psychosomatic Symptomatology of the Palestine Population of Lebanon". Dr Humbert's report reinforced the earlier assumptions that mental and psychological disorders represent a serious problem among refugees in Lebanon, especially children.
In order to improve the situation in the field of mental health, the consultant recommended improving knowledge of psychopathology, diagnosis, patient management and medication, by organizing seminars and conferences in Lebanon for physicians and nurses and sending general practitioners abroad for a placement of 6 to 8 months in a psychiatric polyclinic. They would then become "references" in mental health for their colleagues.
5.3.4.5 During a visit to the University of Manchester, the Director of Health discussed with Dr D. Goldberg, Professor of psychiatry, the mental health problems in the UNRWA's Fields of Operation. The discussions ended with an agreement in principle to organize a training course of 12 months duration in community mental health for five UNRWA medical officers starting October 1992. Annex
5.3.5 Drug Addiction
5.3.5.1 Preparatory work to assess the problem of drug addiction and substance abuse was started in all UNRWA's Areas of Operation. Field Health Officers provided preliminary reports on the magnitude of the problem in their Fields based on information obtained from government and private institutions concerned.
5.3.5.2 The United Nations International Drug Control Programme (UNDCP) agreed to recruit Dr I. Khan, • former Chief of the Psychotropic and Narcotic Drugs Unit, WHO, Geneva, in order to assist UNRWA in conducting a three-month field study to assess the problem of drug addiction in all Fields, to train staff and to make practical recommendations for a plan of action. The mission took place between January and April 1992.
6. NURSING SERVICES
6.1 An Integrated Team Based Approach to Health Care
6.1.1 The Nursing Division has traditionally undertaken a purely supportive role in all Agency health activities • be they curative, preventive or promotive. However, during this reporting period the trend has changed significantly, with the Division actively participating in the provision of an increasing level of team- based health care within the Agency's health service.
6.1.2 The changes referred to above have been reflected at all levels of the service. Senior members of the Division have worked with their colleagues to review and evaluate programme activities, particularly in the area of maternal health care.
These activities resulted in an extensive revision of the maternal health programme and in formulation of a plan to reorganize and upgrade services offered at ante-natal clinics. This process will also entail refining the "At Risk Approach" - which is a system of care that aims to detect women who are "At greater Risk" of morbidity and/or mortality and who are thus in need of more vigilant care during pregnancy. This approach in health care is also designed to evolve in the context of providing a comprehensive system of care for all.
Groundwork has been started, such that the maternal health programme will be developed to include the following elements as an integral part of the programme.
-a family planning service aimed at helping couples to regulate their fertility by spacing the birth of their children; and
-post-natal clinics which will follow up all women within 6 weeks of delivery to determine their state of health, treat/manage any illness they may be experiencing, and provide counselling on birth spacing and management of their child (children).
Nurses will play a key role in the provision of this service as members of a team working with, and supported by, their medical colleagues. The implementation of such an extensive revision of an existing programme will require concerted efforts by all members of the Health Department. Plans are at present under way to train staff to develop new skills - this programme of training will also help staff to improve the way they currently manage the service and their existing skills.
6.1.3 Another instance where nurses are functioning as part of a multidisciplinary team has been in the treatment of noncommunicable diseases • especially in the newly established programme for the management of diabetes. During the reporting period the Nursing Division played a major role in the preparation of the Manual for the Management of Diabetes. This manual has now been published and distributed to all Agency health centres and to public health agencies/institutions throughout the region. Annex
TABLE 4. EXPANDED PROGRAMME ON IMMUNIZATION
Vaccination at maternal and child health centres
Jordan West Gaza Lebanon Syrian All Bank Arab Fields Republic (A) Children who completed full jrimary series No. of surviving infants* 29 600 11 300 25 400 9 000 8 700 84 000 1. Poliomyelitis (TOPV) vaccine No. vaccinated 16 921 10 632 25 294 5 798 6 426 65 071 Coverage rate** 57.2 94.1 99.6 64.4 73.9 77.5 2. Triple vaccine (DPT) No. vaccinated 16 452 10 970 25 392 5 791 6 409 65 014 Coverage rate 56.7 97.1 99.9 64.3 73.7 77.4 3. BCG immunization No. vaccinated 19 049 9 989 23 827 5 548 6 703 65 116 Coverage rate 64.4 88.4 93.8 61.6 77 77.5 4. Measles vaccine No. vaccinated 16 095 9 804 23 017 5 502 6 601 61 019 Coverage rate 54.4 86.8 90.6 61.1 75.9 72.6 (B) Tetanus immunization to pregnant women Tetanus/Toxoid No. under supervision 14 324 10 057 26 227 4 492 5 345 60 445 No. vaccinated 8 802 6 411 22 774 4 850 5 865 48 702 Coverage rate*** 61.4 63.7 86.8 107.9 109.7 81
* No. of surviving infants estimated as follows: Pop. x CBR (1-IMR)
CBR = Crude Birth Rate estimated at 35 per thousand for four Fields and 50 per thousand for Gaza. IMR = Infant Mortality Rate estimated at 40 per thousand.
** Coverage rates were calculated on the basis of estimated number of surviving infants. If they were calculated on the basis of actual number of infants registered at UNRWA maternal and child health clinics, the coverage would be very near 100 percent.
*** Vaccinations include some pregnant women receiving two primary series. Annex
TABLE 5. COMMUNICABLE DISEASES INCIDENCE RATES AMONG EUGIBLE REFUGEES IN 1991
Per 100 000 population
Jordan West Gaza Lebanon Syrian All Bank Arab Fields Republic Population eligible for health services (as at 30.6.91) 881 000 337 000 529 000 268 000 260 000 2 275 000 HIV/AIDS 0.0 0.3 0 0.4 0 0.1 Brucellosis 6.2 62 0.6 1.9 32.3 15.7 Chickenpox 458 539 692 454 1 435 638 Conjunctivitis 1 525 1 915 1 871 1 338 4 519 1 983 Diarrhoeal diseases: Below 3 years (10% of population) 13 590 21 030 23 970 26 760 35 442 21 197 Above 3 years (90% of population) 641 996 1 421 1 565 3 304 1 290 Dysentery (amoebic and ЬасШагу) 381 246 1 072 205 2 974 797 Gonorrhoea 0.2 0 0 0 0 0.1 Infectious hepatitis 12.4 47 34.6 25 207 46 Influenza 254 6 796 3 351 0.7 6 560 2 634 Leishmaniasis (cutaneous) 0.1 0.0 0 0 20 2.3 Measles 6.4 0.3 0 21 3.1 5.3 Meningitis 0.1 0 0 0 0.4 0.1 Mumps 342 288 375 184 781 373 Paratyphoid fever 0 0 0 0 0.8 0.1 Pertussis 0 0 0.6 0 0 0.1 Rubella 9.1 9.8 0.6 72 6.2 14.3 Scarlet fever 0.7 0 0.2 0 12.7 1.8 Trachoma 0.1 0 0 0 1.9 0.3 Tuberculosis (respiratory) 0.1 1.2 0 15.3 16.5 4 Typhoid fever 1.2 0.9 6.2 1.1 11J 3.5 N^u No cases of anlgrlostomiasis, schistosomiasis, cholera, malaria, leprosy, poliomyelitis, syphilis, diphtheria, plague, rabies, relapsing fever (endemic), relapsing fever (louse borne), tetanus (adult) or tetanus neonatorum were reported. Annex
TABLE 6. MATERNAL AND CHILD HEALTH CARE
Jordan West Gaza Lebanon Syrian АИ Bank Arab Fields Republic No. eligible population 881 000 337 000 529 000 268 000 260 000 2 275 000 No. maternal and child health clinics 20 31 17 24 22 114 A. MATERNAL HEALTH CARE (!) Antenatal care No. pregnant women under supervision 14 324 10 057 26 227 4 492 5 345 60 445 (il) Natal care Total delivery registered 9 592 9 314 22 539 4 063 4 425 49 933 -At home (%) 24 24 11 36 37 20 -At Camp Maternity (%) 0 3 34 0.0 0.0 16 -In hospital (%) 76 73 55 64 63 64 B. CHILD CARE Infant O-below 1 year (i) No. under supervision 19 572 10 244 25 795 5 070 6 183 66 864 (ii) Percentage regular attendance 70 76 70 78 83 73 Children 1-below 2 years (i) No. under supervision 17 187 9 158 23 307 5 301 5 837 60 790 (ii) Percentage regular attendance 86 87 65 79 100 79 Children 2'below 3 years (i) No. under supervision 16 197 7 947 21 097 4 850 5 599 55 690 (ii) Percentage regular attendance 84 71 38 76 102* 66 Monitoring of children is carried out on a monthly basis for those below 1 year, bimonthly for age group 1-below 2 years and trimontWy for age group 2-below 3 years.
Figures include repeat visits of children required to attend at shorter intervals for special care. Annex
TABLE 7. PREVALENCE OF GROWTH RETARDATION CHILDREN BELOW THREE YEARS
(Measured by percentage of children with sub-standard weight for age)
Percentage underweight by Degree Field First Second Third All degrees (1) Infants (0-11) months Jordan 1.6 0.4 0.1 2.1 West Bank 1.3 0.4 0.1 1.8 Gaza 1.9 0.6 0.1 2.6 Lebanon 2.1 0.4 0.1 2.6 Syrian Arab Republic 2.2 0.7 0.1 3.0 All Fields 1.9 0.5 0.1 2.5
(2) Children (12-23) months Jordan 2.6 0.3 0.1 3.0 West Bank 1.0 0.2 0.1 1.3 Gaza 2.8 0.8 0.1 3.7 Lebanon 2.4 0.4 0.1 2.9 Syrian Arab Republic 4.8 0.8 0.2 5.8 АИ Fields 2.7 0.5 0.1 3.3
(3) Children (24-35) months Jordan 1.7 0.2 0.0 1.9 West Bank 0.6 0.3 0.0 0.9 Gaza 1.5 0.3 0.0 1.8 Lebanon 0.9 0.1 0.0 1.0 Syrian Arab Republic 2.8 0.4 0.1 3.3 All Fields 1.5 0.3 0.0 1.8
Note: (1) Percentages of 1st, 2nd and 3rd degrees underweight are calculated against the number of infants and children registered in child health centres.
(2) Degrees of underweight are based on the following standard deviations from the international standard weight for age National Centre for Health Statistics (NCHS)/WHO. 1st degree more than 2 SD but less than 3 SD below the mean 2nd degree more than 3 SD but less than 4 SD below the mean. 3rd degree more than 4 SD below the mean.
(3) This is the first year in which the data are based on separate-sex WHO/International weight-for-age standard charts. In previous years data was based on sexes-combined charts. Annex A nurse in each Field has been assigned to the Diabetic Team, which comprises a Medical Officer trained in the management of diabetes, a Health Education Supervisor and the Field Nutritionist. This team visits all Health Centres to teach, advise and assist the staff in the management of diabetic patients. During this reporting period, the emphasis has been on case-finding and counselling individuals so that they understand the disease, and are able to manage their diet and lifestyle in an appropriate manner.
6.1.4 More emphasis has also been put on the team management of growth-retarded children to ensure that the underlying cause(s) of failing to thrive • be it medical, social or economic • is detected and dealt with efficiently. Nurses have been targeted to work as part of the team that follows up these children and their families, both in the health centre and at home during community visits.
6.2 Midwifery and Maternal Health Care in the Occupied Territories
6.2.1 Although the Health Department has undertaken an in depth review of its existing service for maternal health care in all five Fields of operation, the emphasis during this reporting period has been to improve the quality of care provided to pregnant women and nursing mothers in the Occupied Territories.
There is a shortage of hospital facilities in Gaza, and the poor social and environmental conditions people live in are not conducive to safe, clean home deliveries. In an attempt to alleviate the problems that could be associated with home deliveries, UNRWA has maintained and staffed 6 maternity units (60 beds in total) since 1965. UNRWA has also supported the development of a Midwifery Training School in Gaza which provides the majority of the staff for the maternity units. Approximately 34% of all deliveries were undertaken in these units. However, the Maternity Units are old, and require complete renovation and refurbishment with the appropriate kind of modern equipment.
This year UNRWA has been fortunate to secure funds to upgrade and re-equip the maternity units. The aim is to offer a congenial atmosphere whereby a woman who has experienced a normal pregnancy can be delivered by qualified staff in a clean, safe and well-equipped environment. Intra-partum and post-partum care is provided and any deviation from the norm can be reviewed by a Medical Officer and referred to hospital as necessary.
6.2.2 The process of upgrading the Units alone is not enough. There is also a concomitant need both to upgrade the skills of the existing staff and to review and revise extensively the present midwifery training programme to ensure that a hi^i standard of service is offered. With the support of the Save the Children Fund, UK action has been taken to meet both these challenges this year. The Fund provided a technical adviser who worked with senior managers from the Nursing Division to:
-develop a programme of in-service training aimed at commencing the process of upgrading the existing service in West Bank and Gaza;
-review and revise the curriculum and the organization and management of the midwifery training programme.
This whole process will continue during 1992. Save the Children Fund, UK will provide periodic technical assistance to support programme development while financially supporting the next midwifery training programme which is due to commence in September 1992.
Although Gaza is the main emphasis of this programme, staff in the West Bank will also receive the same level of training.
6.3 Qalqilia Hospital
This is a small 36-bed general hospital in the West Bank supported and staffed by UNRWA. The hospital provides four main areas of health care; gynaecology, obstetrics, general medicine and general surgery. Senior health managers concerned about the standard of care provided by this hospital and the Nursing Division played a key role in assisting the Field staff and staff from the hospital to review and revise Annex extensively the manner in which the hospital is organized and managed. At the end of this reporting period there has been a substantial improvement in various aspects of care provided, and in the organization and management of the hospital itself, but there is much room for further improvement.
6.4 Health Centre Assessment
Health Centre Assessment is a management tool aimed at assessing the progress of the various aspects of programme implementation. It can be used to compare the progress being made from one year to the next in key areas of programme development.
Apart from the fact that this will help determine where staff need extra assistance or training, it will also provide the opportunity for senior management to give some form of recognition to staff who have worked hard to implement programmes effectively. The Nursing Division was central to the design and implementation of this assessment during 1991.
6.5 Training
Identifying training opportunities and the required funding is always difficult for the health care profession. The Nursing Division in particular faces many barriers. The number of courses available for the specific training needs of nurses in UNRWA are limited. Moreover, nurses are generally more culturally and socially constrained from leaving their homes and families for any length of time, and an all embracing constraint is reflected in the lack of funds.
UNRWA has been fortunate that the Australian agency APHEDA still supports the training of nurses. Two staff nurses have recently started post-basic midwifery training in the West Bank under APHEDA sponsorship.
The training needs of nurses are many and varied and cannot be met from either existing budgetary provisions or within the existing training approach. As it would be unrealistic to assume that substantially greater funding will be identified, an alternative approach needs to be adopted. The Nursing Division is tackling this problem in two ways:
First, discussions have been held with Bethlehem University in West Bank on the feasibility of providing part-time accredited training programmes tailored to suit UNRWA's training needs.
This would provide a much more cost-effective and relevant method of training, i.e. more staff could be trained, staff would not have to leave their jobs or homes for any length of time, skills could be applied as they are learnt, the quality of training could be monitored and the individuals could receive an accredited certificate or diploma from a recognized institution. These credits could be used to go on for further training at a later date.
Secondly, an area of training which is of concern to the Department is associated with the process of continuous education for the whole of the health care team in all five fields of operation, aimed at both staff development and improved programme implementation. In this context the Nursing Division initiated the establishment of a task force composed of seven individuals from universities that provide training opportunities for staff both in the region and in the United Kingdom. All members of the task force have different skills in the fields of primary or community health care and distance education.
The task force met at UNRWA Headquarters Branch, Amman, during the period 9-18 December 1991, and was requested by UNRWA to work with key managers of the Health Department and the Fields. The overall objective of the Task Force was to assess options for meeting the continuous training and institutional development needs of UNRWAS,s Health Department in the 1990s, via a system of Distance Education.
A fully developed Project Proposal was prepared and finalized during the Task Force. The proposal defined the development of a comprehensive training systems package based on the principles of Distance Education. A consensus emerged towards the end of the meeting to the effect that the proposal offered a Annex unique and innovative means for meeting the comprehensive training needs of health care teams and institutional development requirements of UNRWA's Health Department on a cost-effective and sustainable basis.
7. ENVIRONMENTAL HEALTH SERVICES
7.1.1 Environmental Health Services are provided by UNRWA to about 875 000 refugees residing in 58 camps in the five Fields. The services include provision of safe water supply to meet domestic needs, collection and disposal of refuse, disposal of sewage, management of storm water runoff, and control of insects and rodents of public health importance. However, conditions vary widely from Field to Field, and the environmental health programme in each Field reflects these differences. Where possible these are integrated within, or are provided in cooperation with host governments, municipalities, or other local authorities.
7.1.2 With the exception of water supply, services within the camps are in most cases provided by UNRWA. While UNRWA provides water in some camps, municipalities supply most camps in all Fields. UNRWA monitors water quality in all but one Field in which the government has its own monitoring programme. Whereas in every Field nearly all shelters are provided with toilets, connection to sewerage systems varies from over 80% in the Syrian Arab Republic to about 20% in the Occupied Territories. Solid waste collection within all camps is carried out by UNRWA. However, removal from collection sites and final disposal depends on the capacities of local municipalities to carry out the work, in most cases under contract to UNRWA. Where these services are provided by host governments, municipalities, or other local authorities, UNRWA tries to assure that they meet an acceptable standard. Where these municipalities do not have the capacity to provide services to camps, UNRWA provides them, either directly or through agreement with private contractors.
7.1.3 There are major differences between environmental health programmes in the Occupied Territories and the other Fields. In the Occupied Territories the lack of central authority and local resources limit the capacity for development and management of the sector, and the Intifada has led to special problems. Environmental health problems are most severe in Gaza, where extensive pollution of the environment not only creates a high environmental risk, but also contributes to pollution of the ground water; where heavy use in the domestic water supply and agricultural sectors greatly exceeds recharge, resulting in salt water intrusion from the sea and forcing abandonment of wells; and where insect and rodent control must be a constant effort. As a result, UNRWA plays a larger role in providing environmental health services in Gaza and the West Bank than in the other Fields, and must look forward to a growing role in development within the environmental health sector in these two fields.
7.2 Objectives
The primary objective of UNRWA's environmental health programme is to improve and maintain acceptable environmental health standards in refugee camps in order to reduce morbidity, mortality, and risks of outbreaks associated with poor environmental conditions and practices.
7.3 Strategy
7.3.1 To integrate camp water supplies, sewerage networks, and solid waste management systems within municipal/regional systems.
7.3.2 To increase community participation in improving environmental health standards by involving camp residents in self-help activities and projects.
7.3.3 To seek funding for special capital projects to meet environmental health needs in camps.
7.3.4 To provide a special focus on development in the environmental health sector in the Occupied Territories. Annex
7.4 Progress during 1991
7.4.1 Water Supply
In the Syrian Arab Republic, two water reservoirs, each of 95 m3 capacity provided by UNICEF, were installed at Khan Eshieh and Sbeineh camps.
In Lebanon, and on the request of the Director of Health, WHO/EMRO appointed Dr F. Sharkawi as a short-term consultant to study the situation of water supply, liquid and solid waste disposal in refugee camps. After a six-week mission, Dr Sharkawi submitted a comprehensive report with a master plan for upgrading environmental health infrastructure including water supply, liquid and solid waste disposal and rehabilitation of roads and pathways at an estimated cost of approximately US$ 10.5 million.
Meanwhile, one of the two water reservoirs of 80 m3 capacity was greatly damaged during the fighting in Mieh Mieh camp. The operational hours of the water plants at Mieh Mieh and Ein el-Hilweh camps were increased to overcome the shortage of water there until the damage was repaired.
In Gaza, the acute shortage of water for domestic and agricultural use and the high concentrations of nitrates, which in some areas exceed 20 times internationally accepted standards based on risk to health, continued to receive special attention.
A special study was finalized in September 1991 by Netherlands consultants, which itself was based on analysis of data collected from government and library sources as well as nongovernmental organizations and UNRWA in Jerusalem and Gaza.
The study concluded that the future of Gaza is seriously at risk from environmental degradation which threatens the health of its population and its potential for economic development.
The consultants recommended the formation of a "task force" including technical specialists and all parties involved to plan and organize large-scale projects which they considered vital to achieving solutions to the water problems in the long run.
Meantime, the Agency is considering some immediate solutions to the problem by installation of two water desalination plants in Khan Younis and Rafah, US$ 1.5 million for which were contributed by the Government of Italy.
UNRWA also replaced the corroded water pipes in Beach camp in coordination with Gaza Municipality.
7.4.2 Liquid Waste Disposal
In Jordan, about 97 percent of the main sewerage system at Irbid camp was completed by the water authority.
Works for connection of Wadi-Seer Training Centre to the main sewerage system were completed.
In West Bank, work on Phase I of the construction of an internal sewerage network at Dheisheh camp (laying the main lines and manholes) started on 26 September 1989 and was completed on 21 July 1991. About 3514 metres of main pipes were laid and 172 manholes were constructed. Work on Phase П (laying of the lateral lines) and Phase Ш (house connections) will start as soon as the municipality of Bethlehem completes the external connection line on which work has already started and is expected to be completed by the end of 1992.
Construction of an internal sewerage network at Ama'ri camp is almost complete. About 3979 metres of main and lateral lines have been laid. Work will be completed with respect to the remaining house connections following the agreement with Al-Bireh Municipality. Annex
Meanwhile, design works for the internal sewerage systems for Aida and Beit-Jibrin camps were completed. Work will start as soon as the connecting line within Bethlehem regional sewerage system is completed. Work on laying this line has started and is expected to be completed by the end of 1992.
Funds for implementing the internal sewerage systems at Askar, Tulkarem, Nur Shams and Jenin camps have been allotted from a pledge by the Government of Italy. Work on these projects will start soon.
In Gaza, implementation of Phase I of the Beach camp sewerage scheme i.e. installation of pumping station 3 has not yet started. Although tender documents have been completed, some modifications have been requested by Gaza Municipality, which will take over the responsibility for operation on completion.
Implementation of Phase II i.e. upgrading of pumping stations 1 and 2 and upgrading of the treated effluents pumping station would go paraUel with Phase I.
In Lebanon, construction of sewers in Ein el-Hilweh and Nahr el-Bared camps and rehabilitation of the main drain at Buij el-Barajneh camp were competed.
7.4.3 Solid Waste Disposal
In West Bank, the new skip lifter for Fara'a and Jenin camps started operation in January 1991 while a new compactor truck started operation in August 1991 at Jalazone, Ama'ri and Kalandia camps. Good results were achieved as a result of mechanization of solid waste collection.
In Lebanon, mechanization of garbage collection and disposal was expanded to North Lebanon Area by provision of a garbage truck and matching containers.
In Jordan, an agreement was concluded between UNRWA and the Joint Services Council of Hod el-Baqa'a aiming at integrated disposal of solid waste at Baqa'a camp.
7.4.4 Self-Help Camp Improvements
All Fields were able to implement the projected works for camp improvements on a self-help basis, the Agency providing necessary building material and technical supervision and the refugee community providing the labour force. More than 100 000 m2 of concrete pavements or pathways were laid during 1991.
7.5 Collaboration with other Agencies
UNRWA has received funding for sewerage schemes at Tulkarem in the West Bank and Beach camp in Gaza, which include works within the municipal systems serving the camps, and which will be implemented jointly with the municipalities. Similarly, UNRWA is contributing to the costs of increasing the capacity of a trunk sewer and pumping station constructed within the municipal sewerage system serving Ama'ri camp in the West Bank. UNRWA also has been coordinating with the Bethlehem Municipality, bilateral donors, and UNDP during implementation of the Bethlehem, Beit-Sahour and Beit-Jala sewerage scheme which will serve three camps in the Bethlehem area. Such works, carried out together with municipalities serving camp populations, are needed to increase the capacity of the municipalities to absorb the added burden of serving the camps.
8. NUTRITION AND SUPPLEMENTARY FEEDING SERVICES
8.1 Objectives
The objectives of UNRWA's nutrition and supplementary feeding programme are:
8.1.1 To improve the nutritional status of Palestine refugees through the promotion of the population's knowledge and practice of proper dietary habits. Annex
TABLE 8. ENVIRONMENTAL HEALTH SERVICES
Syrian West Jordan Gaza Lebanon Arab All Fields Bank Republic A. POPULATION SERVED Population 881 000 337 000 529 000 268 000 260 000 2 275 000 No. of camps 10 19 8 12 9 58 No. of camp population 228 000 115 000 289 000 158 000 85 000 875 000 served Percentage of camp to total 26% 34% 55% 59% 33% 38% population B. WATER SUPPLY (i) percentage of families 100% 92% 100% 88% 100% 97% served by indoor connections (ii) percentage served by 0% 8% 0% 12% 0% 3% public points C. WASTE DISPOSAL
(0 percentage of 100% 100% 100% 98% 100% 100% population served by private latrines (ii) percentage of 80% 29% 20% 55% 82% 56% population in camps with sewerage system D. REFUSE DISPOSAL FACIUTIES No. of camps served by:
(i) Incineration 0 4 0 0 0 4 (И) Contractual arrangement (a) with 7 7 0 2 3 19 Municipalities* (b) with private 3 2 0 0 4 9 contractors (iii) UNRWA vehicles 0 6 8 10 2 26 Total 10 19 8 12 9 58
* Including final refuse disposal from three camps, free of charge, by local municipalities, two in Lebanon and one in Syrian Arab Republic Field. Annex
8.1.2 To improve the nutritional status of vulnerable and at risk groups by provision of supplementary food aid.
8.2 Progress in 1991
8.2.1 An alternative strategy to the high-cost, low-impact midday meal programme was introduced at the beginning of 1991. Dry rations were substituted for cooked meals for children who have been in regular attendance to the programme. These will be provided for a transitional period of three years in Jordan and in Syrian Arab Republic and as long as the emergency continues in Gaza, West Bank and Lebanon Fields.
8.2.2 The effective nutritional surveillance system which has been maintained through UNRWA Maternal and Child Health clinics was further strengthened by monitoring of trends on a monthly basis in order to detect any possible deterioration in the nutritional status of the most vulnerable population group, namely children below three years of age. This sort of systematic assessment (which had become more pressing under the prevailing conditions, especially in the Occupied Territories where prolonged curfews, unemployment and worsening economic conditions could have had their adverse effects on the nutritional status of the population) did not reveal any significant difference between the data collected from UNRWA clinics and the findings of the WHO/UNRWA nutrition survey which was conducted in all Fields during 1990 and confirmed that refugee children no longer have a problem of protein energy malnutrition except to a moderate degree in Syrian Arab Republic. (For details please refer to section 5.3.3, Table 7 and accompanying figures.)
8.2.3 Arrangements were also made for partial substitution of a suitable weaning food, i.e. baby cereals for the powdered milk ration for children aged 6-36 months. Full substitution of baby cereal for milk ration is planned in 1992. Meantime, the programme for issue of dry rations to pregnant women, nursing mothers and tuberculosis patients was maintained.
8.2.4 A new strategy for the management of iron deficiency anaemia among pre-school children and women of child-bearing age was introduced at the beginning of 1991.
For practical and operational purposes，the UNRWA criterion cut-off level for the determination of anaemia requiring treatment is a haemoglobin concentration of less than 10 gm for children aged 6-36 months and women of child-bearing age.
Prophylactic management with iron preparations was provided to all pre-school children, pregnant women and nursing mothers.
The treatment of cases whose haemoglobin is below 10 gm is carried out in two distinct stages. The first stage is oral iron therapy, which forms the first line of treatment in virtually all cases. The second stage is parenteral (intramuscular) iron therapy which is resorted to selectively.
Haemoglobin is currently measured by the cyanmethaemoglobin method, by means of spectrophotometers, in all UNRWA laboratories, and by means of colorimeters/haemoglobinometers in all health centres/points where there are no clinical laboratories.
8.2.5 Special emphasis started to be placed on providing education and counselling services for diabetic patients and families of growth retarded children, as well as on groups with special needs.
9. CONCLUSIONS AND FUTURE DIRECTIONS
9.1 In 1991, and indeed since 1988, UNRWA has considerably increased the quantity of its services, both manpower and physical facilities. It has done this despite the grave emergencies of the Intifada, the Gulf crisis and the Lebanon civil wars and their aftermath, and also because of these emergencies, in order to meet increased needs and with the support of increased extrabudgetary funds (Emergency Measures for Lebanon and the Occupied Territories (EMLOT) and the Expanded Programme of Assistance (EPA)). It has also striven to increase significantly the quality and extend the range of services, e.g. in the prevention/management of anaemia, child growth failure, diabetes, hypertension and oral health problems; in Annex the Occupied Territories training staff in emergency medical care; providing physiotherapy; preparing a substantial addition to hospital facilities in Gaza; taking the first steps to creating a mental health capability m all Fields; improving the management and particularly patient flow in Health Centres; improving the quality of prenatal care; studying the circumstances of maternal deaths; taking steps to extend provision of postnatal family planning to all Fields instead of only two.
9.2 Much of this improvement in respect of costs of a recurrent nature has only been made possible by savings made by closing down at the end of 1990 the midday meal programme and, for families of children who had been regular attenders, providing instead a food package (dry rations) which gives the equivalent in energy and protein. (The very low or zero rates of protein-energy malnutrition in the most vulnerable group of children in 1991 despite the adverse economic circumstances, shows how little relationship this midday meal programme in its last years had to do with what was supposed to be the main nutrition problem.)
9.3 For non-recurrent costs of improvement, WHO has provided essential technical cooperation in no fewer than twelve projects or programmes, and WHO, Save the Children Fund, United Kingdom, APHEDA, the British Council and the Government of Norway are supporting training programmes, whilst the European Economic Community collectively, its member states individually, the Governments of Austria, Canada, Japan, the Scandinavian countries, Switzerland and the United States of America have all contributed substantial aid in many forms.
9.4 One may well ask what are the main reasons behind these strenuous efforts? Would it not have been enough to maintain the level of services as it was in 1987 and add to that a few additional measures to meet the specific needs arising from the three emergencies, the Intifada, the Gulf conflict and Lebanon? Why, in addition, such striving to upgrade the range and quality of service? After all, such improvements in themselves augment the number of refugees coming to our Health Centres, as we can very clearly see in the recent annual reports, and thus exacerbating the increase attributable to the grave economic situation in all Fields, accompanied by the steep decline in private medical practice and the expected 16 percent population growth (21 percent in Gaza) since 1987. All these factors themselves result in the Health Department (and the Agency's regular and extrabudgetary resources) having to increase substantially its input just to maintain quantity of service per 1000 refugees.
Thus in 1990 the average number of medical consultations (most of them accompanied by a prescription for essential drugs which are virtually never out of stock, all gratis) was over 100 per doctor per day. As for Maternal and Child Health services, each of the 60 000 pregnancies per annum registering with UNRWA Health Services entails an average of 6 visits for prenatal care, optimally at least one postnatal care/family planning visit, at least 12 visits for child care including at least 6 for immunization (plus 8000 deliveries at UNRWA maternities in West Bank and Gaza and several million dollars to subsidize deliveries elsewhere). The total number of Maternal and Child Health visits to our Health Centres is therefore in the region of 100 000 per month. We have about 600 nurses and midwives working in our Health Centres, and even if we were able to put them all fùll-time on to Maternal and Child Health routine service (which is quite impossible considering their other duties) it would only just enable adequate time and attention for all these women and infants. The introduction of an appropriate postnatal and family planning service will demand additional human resources, but such care has now become the most pressing unmet need for maternal and newborn health.
9.5 UNRWA is almost the only health service in the area providing care to the inhabitants totally without even nominal charge at the point of service. A consideration of other services shows that they have a tax basis or a health insurance scheme to support the costs. UNRWA has only a regular budget which invariably fails to increase year-by-year by an amount to cover increases in population plus even the most modest estimate of inflation in costs per item or per staff member. Yet any proposal to levy a charge, however nominal, at the point of service is resisted vigorously and is impossible to implement in present circumstances.
9.6 To return then to the earlier question, why then does the UNRWA Health Department, snared in effect in a thorabush of constraints and contradictions, set itself not merely to maintain the level of its services but to extend their range and improve their quality? There are two reasons: the first relating to the Palestine refugees themselves, and the second which concerns the credibility on the ground of the United Nations and Annex
WHO. The first reason is that all the three emergencies which the Palestinian people face, Lebanon, the Intifada and the Gulf conflict, each in its own way has caused a much higher international priority than before to be attributed to the solution of the problem of Palestine in the context of peace in the Middle East. Sooner or later ever-increasing international concern and involvement will lead to this solution, bringing nearer the day when UNRWA will hand over its responsibilities in health to the Palestinians themselves. It is perfectly understandable and proper in human terms that UNRWA should wish to hand over a health system which is as close to international norms and as cost-effective as possible, which is primary health care oriented, which is able to be integrated with other services without difficulty, and which reflects some of the progress in public health which the Palestinians would have achieved in the last 45 years if only they had been left in peace. Admittedly, the time when this handover of responsibilities takes place may be some distance away yet, but real reform and progress cannot be hurriedly arranged the day before.
9.7 The second reason is that the Palestinian refugees are the only population for whose health services the United Nations has agreed to take long-term direct responsibility. Two of its agencies, UNRWA and WHO, made an agreement in 1950 for this purpose. Here is where they not only have to talk, but do, not only to advise or coordinate but to act, in a quasi-governmental, executive role. Here is an opportunity for the United Nations and WHO to implement their own oft-stated policies and create, despite adversity and severe constraints, a realistic and cost-beneficial primary health care system. We must accept that the unremitting search for improvement in quality as well as quantity is obligatory, and at the very heart of the two agencies' mission and mandate.
9.8 However, even these sentiments would be empty if we could not express them in more concrete and accountable targets and goals. In my Annual Report for 1988 (pages 41-42) seven goals were set for the next few years. Towards achieving five of these much progress has been made in three years, the exceptions being environmental health and community participation. It is time now to state again our priority objectives and define them even more concretely. For the four years 1992-1995,1 suggest these priorities should be as follows:
(1) Given that in the Palestinian population short birth intervals, grand multiparity and childbearing over the age of 40, together constitute the greatest cause of maternal and neonatal Ul-health and mortality, the UNRWA health staff will endeavour to discuss with every woman for whose maternal care we accept responsibility, her own wishes in respect of child spacing and fertility regulation, and will offer to her such assistance as she and her husband require.
(2) UNRWA will endeavour to the best of its financial means to increase the number of doctors and nurses and midwives so as to bring the daily number of patients per doctor, and improve the management of Health Centres, to a level where there is sufficient patient-contact time for the doctor and Maternal and Child Health staff to fulfil to an acceptable standard the roles for which they were trained and appointed.
(3) UNRWA will aim to complete and open a first-class 232-bed general hospital in the Gaza Field, to relieve some of the most acute needs of the population, involving maximum possible Palestinian participation in decision-making in policy and management.
(4) UNRWA's highest priority in respect of external funding in health will, however, be given to environmental health, and in particular to planning and the first part of implementation of master plans for sewage disposal and safe water supply in Gaza, West Bank and Lebanon, in that order of priority. This will be done in cooperation with others who share UNRWA's responsibility to resolve the present grave problems in these Fields.
(5) At the level of health centres and camps and at the level of each field, the Health Department will endeavour to create consultative mechanisms which will express the Palestinians' own priorities In health care concomitant with their participation in trying to attain these. These mechanisms can be formal or informal. Despite factionalism and other political constraints, UNRWA and WHO will sincerely try to replace the present provider-consumer dependency relationship with a real working Partnership in Health.